Understanding the Elimination Period
This is the policy’s “deductible.” Often abbreviated EP, it is usually expressed as a number of days. You will find the number of ELIMINATION PERIOD days clearly stated on a policy's SCHEDULE OF BENEFITS page. But when and how those days are counted can be very different depending on the policy and what type of care is used; you must look for the detailed definition of the EP in the policy's internal language, and sometimes you have to look in several different places to fully understand how it works for home care benefits.
Again, first you must be disabled/impaired based on one of the BENEFIT TRIGGERS for the EP to start. An EP is not simply a waiting period, rather it is designed to count the number of days you are BENEFIT ELIGIBLE and receiving a covered care service.
Newer policies only require the EP be satisfied once and can combine both days of care in a facility and home care days. Older policies may require a new EP for separate periods of care and may have separate EPs for facility or home care. A policy may set a total dollar amount that must be spent before benefits begin, but this is very rare.
Again, first you must be disabled/impaired based on one of the BENEFIT TRIGGERS for the EP to start. An EP is not simply a waiting period, rather it is designed to count the number of days you are BENEFIT ELIGIBLE and receiving a covered care service.
Newer policies only require the EP be satisfied once and can combine both days of care in a facility and home care days. Older policies may require a new EP for separate periods of care and may have separate EPs for facility or home care. A policy may set a total dollar amount that must be spent before benefits begin, but this is very rare.
CLAIM TIP: Always work to file a claim as soon as possible. This starts the EP clock running sooner, and is very valuable if your policy has a one-time EP - once it's satisfied it never comes back. You can "turn off" your claim after the EP is satisfied until you are ready for home care services to start again.
The EP is the most-misunderstood element at claim time, and after premium increases, it is the most-complained-about feature to insurance commissioners.
For care that starts in a facility - a nursing home or assisted living for example - the EP is easy: you are there every day, receiving care every day, and subject to a charge every day, so every day will count toward the EP.
For care that starts at home, there are FOUR (4) different ways the EP could be counted:
For care that starts in a facility - a nursing home or assisted living for example - the EP is easy: you are there every day, receiving care every day, and subject to a charge every day, so every day will count toward the EP.
For care that starts at home, there are FOUR (4) different ways the EP could be counted:
Satisfying the Elimination Period with Home Care"Calendar Days"
A Calendar Day EP simply counts the days that you are determined to be BENEFIT ELIGIBLE, in other words it only counts days of "disability" no matter who takes care of you - it could be your spouse or family during the EP. Some policies start counting when it can be determined you were BENEFIT ELIGIBLE, even if that date was in the past allowing for a claim to start more quickly after being filed. Other Calendar Day EP policies only start the "calendar" once the company has approved your claim even if the impairment started earlier. This is a reason to file a claim as soon as possible once you begin to see signs of an impairment. This how most people - clients and agents - think the EP works. It is the easiest to understand and generally the best type of EP to have, but it is also the LEAST common. "Cash benefit indemnity" policies use a Calendar Day EP because they never measure actual expenses or the type of care received to pay benefits. "Service Days"
This is the most-common, most-misunderstood, and most problematic type of EP for home care benefits. In order for a day to count in a Service Day policy, you must not only be BENEFIT ELIGIBLE, but you must also be receiving and paying for home care services that would otherwise be covered by the policy. Because most policies exclude coverage for "informal" caregivers, If your spouse or a family member is the only one who takes care of you in a day, that day will NOT count toward the EP. Or if you contract with a home care agency that does not meet your policy's requirements/definitions to be a covered provider, those days will not count either. If you have a 90-day EP that uses Service Days for home care, you must actually receive and pay for 90 days of policy-covered, approved, professional caregiving services. CLAIM TIP: Negotiate with the home care agency to reduce their minimum number of hours during the EP so you can have covered services every day and keep your out-of-pocket costs down while satisfying the EP. You can increase hours after the EP is satisfied and benefits being paying. "Service Days with Credit"
This is a very common alternative in many Service Day EP policies. While the policy still requires paid, covered "days of service" to count the EP, it will give you a full week's credit (7 days) if you only have one (1) day of paid, covered care in the week (Sunday to Saturday). This may also be called a "Weekly EP". (This is the way that most policies from John Hancock, Northwestern Mutual, Prudential, and UNUM work.) A few older policies required three (3) days of paid, covered care before crediting seven days for the week. Understanding how many days of home care each week are required to move the EP is a critical piece of information at claim time, and these Service Day credits are often buried inside a policy's technical language. Some policies have an "Accumulation Period" which is a set period of time within which you must satisfy the EP. It is usually three-times the EP. So a 90-day EP with a 3x Accumulation Period requires the EP be fully met within 270 days; if it is not, then the EP re-sets to day one. (UNUM's employee benefit group-based LTC insurance policies not only have an Accumulation Period, but it requires that the days be "consecutive", so if you miss getting at least one day of care in a week, the whole EP starts over again.) "0-Day EP for Home Care"
This may be built into a policy or noted as a separate home care provision. Sometimes this is a rider, and it may be called "Waiver of EP for Home Care" - making the ELIMINATION PERIOD for home care zero (0) days. You should be able to identify if you have this option on the policy's Schedule of Benefits. This is obviously the very best type of EP to have for home care as there is no EP at all. You still must be BENEFIT ELIGIBLE, but benefit payments for covered home care services can start on day one. NEXT: Caregiver Eligibility >< BACK: Benefit Eligibility |
* NOTE: This information is for educational, informational purposes only and is not meant to provide specific guidance for any particular policy, policyholder, or claim situation. LTCI elimination period crediting is determined by the insurance carrier based on the specific criteria in the issued policy contract and the carrier's own guidelines.